Grand Oaks Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Tulare, California.
- Location
- 897 North M Street, Tulare, California 93274
- CMS Provider Number
- 555861
- Inspections on file
- 46
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Grand Oaks Care during CMS and state inspections, most recent first.
A resident with recurrent UTIs and hematuria had a physician’s order for a urology consult, but facility staff did not complete or document the referral. During interviews and record reviews, the DON and ICP confirmed the existence of the order and the absence of any documentation that a urology referral was made, indicating the order may have been missed. This was not consistent with the facility’s policy requiring timely submission of physician-ordered services, resulting in the resident not being evaluated by a urologist and creating the potential for untreated urinary tract disease.
A LVN worked 22 days without a current license, as confirmed by the DON and employee records. The LVN's job description required a current unrestricted license, but the facility failed to ensure this qualification was met.
A resident with a history of anxiety and aggression repeatedly refused prescribed Buspirone, but the attending physician was not notified as required by facility policy. This lack of notification coincided with an incident where the resident physically injured another resident, and staff confirmed the resident's ongoing behavioral issues and need for close supervision.
A resident experienced a significant change in condition, including gurgling throat sounds, burning sensation during urination, increased confusion, and throat pain. While the physician was notified and new orders were given, there was no documentation that the responsible party was informed, as required by facility policy. The ADON confirmed the omission during record review.
A resident experienced multiple episodes of significantly elevated blood glucose over several days, but nursing staff failed to notify the physician as required by orders and facility policy. This lack of notification and documentation led to the resident being hospitalized with severe hyperglycemia, dehydration, and hypernatremia.
A facility failed to implement a care plan requiring 1:1 supervision for a resident with aggressive behavior. The resident was left alone in their room without supervision, contrary to the care plan and facility policy. The assigned Nursing Assistant did not arrange for coverage during her break, leading to the lapse in supervision.
The facility failed to implement an effective QAPI program as required by its policy. The last QAPI meeting was held in September 2024, and the plan lacked measurable data and goals. The Administrator admitted to not having analytical data for Process Improvement Projects, and the QAPI reports did not include measurable data for monthly monitoring and evaluation.
The facility failed to ensure call lights were within reach for five residents, potentially delaying care. Observations revealed call lights on the floor for residents requiring substantial assistance, contrary to facility policy.
The facility failed to complete Advance Directive Acknowledgement forms for ten residents, with no documentation showing they were informed of their rights to formulate an AD. Interviews revealed that residents and family members were not provided with necessary information, despite the facility's policy requiring it.
A GVN administered narcotics without supervision, using the ADON's EPHI access, leading to unauthorized access and potential record falsification. Additionally, wound care treatments for three residents were not documented, indicating non-compliance with physician orders.
The facility failed to maintain RNA program orders for three residents, leading to potential avoidable reductions in their range of motion. One resident with contractures and impaired mobility did not have orders for passive range of motion exercises, while another with joint mobility issues lacked orders for assisted exercises. Additionally, a resident with hand contractures did not have palm protectors applied as required. The facility did not adhere to its policy on providing appropriate services for residents with limited mobility.
The facility failed to complete performance evaluations for two CNAs and an LVN, as competency checklists were missing or outdated. CNA 3 and LVN 1 lacked completed checklists before working independently, and CNA 5's checklist was overdue. The facility could not provide their staff competency policy when requested.
The facility failed to complete quarterly social services assessments for nine residents, with some assessments overdue by up to 16 months. This oversight was acknowledged by the Social Services Supervisor and was contrary to the facility's policy, potentially delaying necessary social services for the residents.
The facility failed to act on pharmacy recommendations for Medication Regimen Review (MRR) in July 2024, potentially leading to adverse health outcomes for residents. A review revealed 99 unaddressed pharmacy recommendations with no physician notification, and 55 recommendations lacking a final response. The DON admitted to not verifying the completion of these recommendations, contrary to the facility's policy requiring action on all recommendations.
The facility failed to properly label and store medications, leading to potential contamination and unauthorized access. Two opened medication bottles lacked open date labels, and a resident's medications were improperly stored in a cart. Additionally, 50 OTC medication bottles were accessible to unauthorized personnel, and a resident's medication was stored at the bedside without evaluation. These actions violated the facility's policies on medication safety.
The facility failed to implement proper infection control practices, including inadequately covered linen carts, staff not following enhanced droplet and contact precautions, a resident's room not being deep cleaned before another resident moved in, and a nurse not performing hand hygiene after glove removal. These lapses had the potential to transmit infectious diseases.
The facility failed to store chemical containers properly in the laundry room, with five chemical containers and a bleach bottle found on the ground. The Laundry Personnel acknowledged the containers should be stored above ground, and the Administrator confirmed that items should be at least four inches off the ground. The facility's policy on chemical storage was not provided upon request.
A resident was found to have items in their room that belonged to another resident, causing discomfort and confusion. A CNA confirmed that the items belonged to a different resident who had moved rooms. The facility's policy on maintaining a homelike environment was not followed, as it emphasizes the use of personal belongings and personalized room arrangements.
The facility failed to notify the Long Term Care Ombudsman of the transfer and discharge of two residents, as required by policy. For both residents, there was no fax confirmation that the ombudsman received the notice, and the Social Services Supervisor was unsure if the notifications were sent. The facility's policy mandates maintaining evidence of such notifications, which was not followed.
A facility failed to implement necessary interventions to prevent skin breakdown for a resident at high risk of pressure ulcers. The resident's heels were not elevated as required, despite having non-blanchable redness on the left heel. The resident's care plan and Order Summary Report indicated the need for a 'heels up' device, which was not properly utilized. The resident had a high-risk Braden Scale score and required total assistance with bed mobility, highlighting the need for adherence to the facility's pressure ulcer prevention policy.
A facility failed to follow its medication reordering and unavailable medication policies, resulting in a resident missing doses of critical diabetic medications. The licensed nurse did not reorder medications timely, notify the physician, or obtain alternative orders, leading to missed doses of Admelog, Jardiance, Lasix, and Tresiba. Interviews revealed that the facility's policy required medications to be reordered when six or fewer doses remained, and the physician should have been notified of missed doses, which was not done.
A facility failed to follow a physician's order for a resident requiring nectar thick consistency beverages, risking a choking incident. Observations revealed the resident had unthickened juice and soda, contrary to the order. The care plan did not address the resident's noncompliance, and the facility's policy on using commercially-prepared thickened liquids was not followed.
A resident, who was cognitively intact, expressed dissatisfaction with a meal that included brussels sprouts, which he disliked. Despite having specified his vegetable preferences, the facility failed to provide an alternative meal, contrary to their policy. This oversight had the potential to result in unmet nutritional needs.
The facility failed to serve food at the proper temperature for two residents, resulting in meals being served at unappetizing temperatures. Observations revealed that one resident received lukewarm breakfast items, while another reported cold food. Temperature checks showed that the food items did not meet the facility's policy requirements for hot and cold food temperatures.
The facility failed to ensure that four CNAs wore name tags, leading to residents and visitors being unable to identify staff. Observations and interviews revealed that CNAs either misplaced, forgot, or lost their name tags, contrary to the facility's policy requiring visible identification badges during work hours.
A facility failed to implement its abuse policy when an LVN did not report abuse allegations involving two residents to management. The LVN was informed by a resident that a CNA had allegedly been abusive, but did not report it, assuming the DON was already informed. Interviews with the ADON and Administrator confirmed that staff must report abuse allegations immediately. The facility's policy requires reporting within two hours if abuse is involved.
The facility failed to notify the Physician and Responsible Party (RP) of a resident's injury after a fall. The resident returned from the emergency room with abrasions to bilateral shins, but there was no evidence of notification to the Physician and RP. The Director of Nursing confirmed this oversight, which is against the facility's policy requiring notification of changes, including accidents resulting in injury.
A resident's call light was found to be non-functional, which could prevent staff from being aware of the resident's need for assistance. The issue was confirmed by a CNA and the Maintenance Director, and it was noted that the facility's policy requires call lights to be functional at all times.
The facility failed to ensure that monitoring and wound care were completed as ordered by the physician for two residents. Documentation indicated that monitoring and treatments were missed on multiple occasions, which was confirmed by the Treatment Nurse and the Director of Nursing.
A resident was not administered Bumetanide, a vital medication for congestive heart failure, for three consecutive days due to awaiting pharmacy refill and pending delivery. The facility failed to notify the physician of this lapse, as required by their policy. The DON confirmed the lack of documentation regarding physician notification.
A facility failed to document the administration of medications for a resident, resulting in an inaccurate MAR. The resident was receiving treatment for various conditions, including irregular heart rate and hypertension. The DON confirmed that medications were administered but not recorded, contrary to the facility's policy.
The facility failed to develop a baseline care plan for a resident admitted with a partial thickness wound to the coccyx area. The DON confirmed the absence of documented evidence for the required care plan within 48 hours of admission, as per facility policy.
The facility failed to provide wound care as ordered for a resident, as documented in the Treatment Administration Record. The Director of Nurses confirmed the lapse in care, which was not in accordance with the facility's wound treatment management policy.
Failure to Complete Physician-Ordered Urology Referral for Resident With Hematuria
Penalty
Summary
The facility failed to ensure services met professional standards of quality when staff did not carry out a physician’s order for a urology referral for Resident 1. A physician’s order dated 5/12/25 directed that Resident 1 be referred to urology for evaluation of hematuria (blood in the urine). During interview and concurrent record review on 3/12/26, the DON confirmed that Resident 1 had this order but there was no documented evidence that the urology referral had been made, and acknowledged the referral should have been completed. In a separate interview, the Infection Control Preventionist stated that Resident 1 had recurrent UTIs and that the physician had ordered a urology consult on 5/12/25, but upon reviewing the clinical record was also unable to find documentation that the referral was initiated, stating the order might have been missed. Review of the facility’s policy “Provision of Physician Ordered Services” indicated that qualified nursing personnel are required to submit timely requests for physician-ordered services, including consultations, to the appropriate entity, which was not followed in this case. This failure resulted in Resident 1 not being seen by a urologist and created the potential for untreated urinary tract disease, as noted in the report.
Unlicensed LVN Provided Resident Care
Penalty
Summary
The facility failed to ensure that one of four sampled Licensed Vocational Nurses (LVN) was qualified to provide resident care, as the LVN worked without a current license. Review of the LVN's employee file showed that their license had expired, yet the work schedule indicated the LVN continued to work for 22 days after the expiration. The Director of Nurses (DON) confirmed that the LVN worked these days without a valid license and acknowledged that the LVN should not have been working without a current license. The facility's job description for Charge Nurse, which the LVN had signed, required a current unrestricted license as a Registered Nurse (RN) or LVN in the practicing state.
Failure to Notify Physician of Repeated Medication Refusals Leading to Resident Altercation
Penalty
Summary
The facility failed to follow its own policy and procedure regarding physician notification for a resident who repeatedly refused an ordered medication. Specifically, a resident with a physician's order for Buspirone to manage anxiety and unprovoked physical aggression refused the medication multiple times over several months, with documented refusals ranging from 55 to 57 times per month. Despite the facility's policy requiring the attending physician to be notified after two or more consecutive refusals, there was no documented evidence that the physician was informed of these refusals. As a result of the ongoing medication refusals, the resident exhibited aggressive behavior, including a physical altercation in which the resident grabbed another resident's arm, causing a skin tear and bleeding. Staff interviews confirmed the resident's history of aggressive behavior and the need for a one-on-one sitter. The Director of Nursing reviewed the records and confirmed that the policy for physician notification was not followed.
Failure to Notify Responsible Party of Change in Resident Condition
Penalty
Summary
The facility failed to notify the responsible party when there was a change in condition for one of the sampled residents. Specifically, a resident experienced gurgling sounds in the throat, burning sensation during urination, increased confusion, and throat pain. The physician was notified and provided orders for suction as needed, a speech therapy evaluation, and increased fluids. However, there was no documentation that the resident's responsible party was informed of these changes. During an interview and record review, the Assistant Director of Nursing confirmed that the responsible party was not notified, which was contrary to the facility's policy requiring notification of a resident's representative in the event of a significant change in the resident's status.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician of a resident's change in condition as required by physician orders and facility policy. Specifically, the resident had multiple blood glucose readings significantly above the ordered threshold of 200 mg/dL over several consecutive days. Despite the physician order to notify for blood sugars greater than 200 mg/dL, there was no documentation that the physician was informed of these elevated results. Interviews with nursing staff confirmed that notifications were either not made or not documented, and one nurse was unaware of the notification requirement in the physician's order. The Director of Nursing also confirmed the lack of documentation and acknowledged that the physician should have been notified immediately when the resident's blood sugar exceeded the specified limit. As a result of the failure to notify the physician, the resident experienced a significant decline, presenting with symptoms such as a deep chest cough, elevated pulse, and high fever, which led to a transfer to the hospital. Upon admission, the resident was diagnosed with severe hyperglycemia, dehydration, and hypernatremia, with critical lab values indicating a life-threatening condition. The facility's own policies required staff to incorporate physician notification parameters into care planning and to notify the physician of changes in the resident's condition, but these procedures were not followed in this case.
Failure to Implement 1:1 Supervision for Aggressive Resident
Penalty
Summary
The facility failed to implement a care plan for a resident who was known to exhibit physically aggressive behavior. The care plan, dated December 16, 2024, required the resident to have 1:1 supervision at all times due to their aggressive tendencies. However, on January 29, 2025, the resident was observed alone in their room without supervision. The Director of Nursing confirmed that the resident should have been under constant supervision. The Nursing Assistant assigned to the resident admitted to leaving the resident alone without arranging for another staff member to cover during her break. This lapse in supervision was contrary to the facility's policy and procedure for comprehensive, person-centered care plans, which emphasize the importance of implementing interventions to maintain the resident's well-being.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to adhere to its Quality Assurance and Performance Improvement (QAPI) policy and procedure, which is a data-driven, proactive approach to improving the quality of care and services. During an interview and record review, it was found that the last QAPI meeting was held in September 2024, and the QAPI plan was not effective. The Administrator admitted that there was no measurable data discussed for completing nursing staff competencies, and the analytical data was not available for Process Improvement Projects (PIPs). The QAPI reports lacked measurable data that were being monitored and evaluated monthly, and the QAPI goals were not measurable. The facility's policy and procedure on QAPI, dated February 2020, required the development, implementation, and maintenance of an ongoing, facility-wide, data-driven QAPI program focused on indicators of care outcomes and quality of life for residents. Key components included tracking and measuring performance, establishing goals and thresholds for performance measurement, and systematically analyzing the underlying cause of systemic quality deficiencies. However, the facility did not follow these procedures, as the QAPI committee did not meet monthly to review reports, evaluate data, and monitor QAPI-related activities, leading to the deficiency.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for five of the 18 sampled residents, which could potentially delay care and assistance. During observations and interviews, it was noted that the call lights for Residents 33, 50, 64, 67, and 63 were found on the floor, out of reach. Certified Nursing Assistant (CNA) 3 observed Resident 33's call light on the floor and stated it should have been clipped to the resident's blanket. Resident 33's Minimum Data Set (MDS) indicated severe cognitive impairment and required maximal assistance for upper body dressing and mobility, with a care plan intervention to keep the call bell within reach. Similarly, Resident 50's call light was found on the floor during an observation with a Restorative Nurse Assistant (RNA), who confirmed it should have been within reach. Residents 64 and 67 also had their call lights on the floor, and both required substantial to total assistance with self-care and mobility. Resident 63, who had moderate cognitive impairment and required substantial assistance, was unable to find the call light, which was also on the floor. The facility's policy stated that staff should ensure call lights are within reach and secured, but this was not adhered to in these cases.
Failure to Complete Advance Directive Acknowledgement Forms
Penalty
Summary
The facility failed to ensure that an Advance Directive Acknowledgement (ADA) form was completed for ten out of twenty sampled residents. During interviews and record reviews, it was found that residents had not completed an Advance Directive (AD), and there was no documentation to show that they were offered or received information about their right to formulate an AD. This was observed in multiple cases, including Resident 443, Resident 40, and Resident 20, among others. The Admission Coordinator (AC) confirmed that the ADA forms were incomplete and that there was no evidence of information being provided to the residents regarding ADs. Further interviews revealed that Resident 18, who had a moderate cognitive impairment with a BIMS score of 12, did not remember being provided information on ADs and expressed a desire for more information. The Social Services Supervisor (SSS) also confirmed the lack of documentation for Resident 18. Additionally, a family member of Resident 18 stated that neither they nor the resident were provided information on the right to formulate an AD. Similar findings were noted for other residents, such as Resident 6, Resident 37, and Resident 51, where the ADA forms were incomplete, and there was no documentation of information being provided. The facility's policy and procedure on Advance Directives, dated September 2022, indicated that residents have the right to formulate an AD and should be provided with written information about their rights. However, the facility failed to adhere to this policy, as evidenced by the incomplete ADA forms and lack of documentation for the residents involved. This failure had the potential to result in the residents' wishes or health choices not being honored.
Unauthorized Medication Administration and Incomplete Wound Care Documentation
Penalty
Summary
The facility failed to ensure proper supervision and adherence to professional standards of quality in medication administration and documentation. A Graduate Vocational Nurse (GVN), who was unlicensed, was found administering narcotics to residents without the supervision of a licensed nurse. This occurred for three residents, where the GVN used the Assistant Director of Nursing's (ADON) electronic protected health information (EPHI) access code to document medication administration, including controlled substances like Morphine Sulfate and Oxycodone HCL. The ADON confirmed that the GVN was not authorized to dispense or sign off on controlled medications independently, and the GVN's actions resulted in unauthorized access to residents' protected health information and potential falsification of medical records. Additionally, the facility failed to follow physician orders regarding wound care treatment documentation for three residents. The Treatment Administration Records (TAR) for these residents were missing licensed nurse initials, indicating that the required wound care treatments were not documented as completed. The Director of Nursing (DON) confirmed that the absence of initials meant the treatments were not performed. The facility's policies and procedures required that treatments be documented on the TAR or in the electronic health record, which was not adhered to in these instances.
Failure to Maintain RNA Program Orders for Residents
Penalty
Summary
The facility failed to ensure that three residents had appropriate Restorative Nurse Assistant (RNA) program orders, which are essential for maintaining or improving their range of motion. Resident 47, who has contractures and impaired functional range of motion due to hemiplegia and hemiparesis, did not have RNA program orders for passive range of motion exercises. Similarly, Resident 48, who has impaired joint mobility and decreased ability to perform activities of daily living independently, lacked RNA program orders for active assisted range of motion exercises. Both residents' care plans indicated the need for these interventions, but the orders were not renewed as required. Additionally, Resident 51, who has functional limitations in the range of motion of both upper extremities and contractures in both hands, did not have palm protectors applied as per the RNA order. The order for palm protectors, which was intended to protect the skin integrity and prevent pressure wounds, was not renewed after it was completed in August 2024. The facility's policy on resident mobility and range of motion, which mandates appropriate services and equipment for residents with limited mobility, was not adhered to in these cases.
Failure to Complete Staff Competency Evaluations
Penalty
Summary
The facility failed to complete performance evaluations for three out of eight sampled employees, which included two Certified Nursing Assistants (CNAs) and one Licensed Vocational Nurse (LVN). During interviews and record reviews, it was found that CNA 3 and LVN 1 did not have their competency checklists completed prior to working on the floor alone, despite being hired on 8/1/24 and 7/1/24, respectively. The Director of Staff Development (DSD) confirmed the absence of these checklists and acknowledged that they should have been completed before the employees began working independently. Additionally, CNA 5's most recent competency checklist was completed on 7/7/23, and the DSD admitted that CNA 5 was due for an annual review and competency checklist in July of the current year, which had not been completed. The Assistant Director of Nursing (ADON) also confirmed that LVN 1 did not have a competency checklist completed upon hire. The facility was unable to provide their policy and procedure on staff competency when requested, further highlighting the deficiency in ensuring staff competencies were evaluated and documented as required.
Failure to Complete Quarterly Social Services Assessments
Penalty
Summary
The facility failed to ensure that social services assessments (SSA) were completed quarterly for nine of the 19 sampled residents. This deficiency was identified during an interview and record review with the Social Services Supervisor (SSS), where it was found that the SSAs for several residents were significantly overdue. Specifically, Resident 51's SSA was 11 months overdue, Resident 63's was 15 months overdue, Resident 71's was 11 months overdue, Resident 44's was 13 months overdue, Resident 27's was 15 months overdue, Resident 6's was 13 months overdue, Resident 54's was 6 months overdue, Resident 47's was 16 months overdue, and Resident 48's was 16 months overdue. The facility's job description for Social Services, dated December 5, 2012, and the policy and procedure titled 'Social Services,' dated February 2023, both indicated that SSAs should be completed on a quarterly basis. The SSS acknowledged that the assessments should have been conducted every three months, as per the facility's guidelines. This failure to conduct timely assessments had the potential to delay the provision of medically related social services, thereby affecting the psychosocial needs of the residents.
Failure to Act on Pharmacy Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to act on pharmacy recommendations for Medication Regimen Review (MRR) for the month of July 2024, which had the potential for residents' adverse health outcomes due to the physician not being notified of the pharmacy recommendations. During a review of the facility's Psychotropic & Sedative/Hypnotic Utilization by Resident (PSHUR) for July 2024, it was found that there were 99 pharmacy recommendations that the facility did not act on, with no documentation of physician notification. The Director of Nursing (DON) confirmed that the July 2024 pharmacy recommendations were not acted upon and admitted to not checking if they were completed. Additionally, a review of the Consultant Pharmacist's Medication Regimen Review Active Recommendations Lacking a Final Response (CPMRRARLFR) for the same period indicated that there were 55 pharmacy recommendations not acted on. The DON stated that the Assistant Director of Nursing (ADON) did not complete the CPMRRARLFR in July 2024 and acknowledged not verifying its completion. The facility's policy and procedure on Medication Regimen Review required staff to act upon all recommendations according to the procedures for addressing medication regimen review irregularities.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to several deficiencies. Two opened medication bottles in the medication storage room were not labeled with an opened date, which could lead to potential contamination. Additionally, three bottles of medications for a resident were found in a plastic bag in a medication cart drawer, despite the resident's current medications being stored elsewhere. This oversight could result in the administration of discontinued or outdated medications. Furthermore, approximately 50 over-the-counter medication bottles were not securely stored, allowing unauthorized personnel access, and a resident's medications were not safely stored, posing a risk of access by unauthorized staff and residents. During observations, it was noted that the facility's policies and procedures were not followed. The Assistant Director of Nursing acknowledged the lack of open date labels on medication bottles and the improper storage of a resident's medications. The Director of Nursing confirmed that non-nursing staff had access to a storage room containing medications, and a Licensed Vocational Nurse identified a resident's medication stored at the bedside without a self-medication evaluation. These findings indicate a failure to adhere to the facility's policies on medication labeling, storage, and self-administration, potentially compromising medication safety and security.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to implement proper infection prevention and control practices in several instances. One of the clean linen carts was observed to be inadequately covered during transport, with a five-inch opening due to an ill-fitting cover. This was acknowledged by the laundry personnel and the infection preventionist, who confirmed that the linen cart should have been entirely covered as per the facility's policy. Additionally, four staff members, including CNAs and a nursing consultant, did not adhere to enhanced droplet and contact precautions. This included failing to change N95 masks after exiting isolation rooms and neglecting to wear appropriate personal protective equipment (PPE) such as gowns, face shields, and gloves when entering rooms with posted precautionary signs. Furthermore, a resident's room was not deep cleaned before another resident moved in, leaving personal items from the previous occupant, which was confirmed by the housekeeper and infection preventionist. The housekeeper stated that deep cleaning was contingent on the removal of personal belongings, which had not been done. Lastly, a licensed vocational nurse failed to perform hand hygiene after removing gloves and before handling clean supplies in a resident's room, contrary to the facility's hand hygiene policy. These lapses in infection control practices had the potential to transmit infectious diseases within the facility.
Improper Chemical Storage in Laundry Room
Penalty
Summary
The facility failed to properly store chemical containers in the laundry room, which posed a potential risk to the health and safety of staff and residents. During an observation and interview, it was noted that five chemical containers and one bleach bottle were placed on the ground next to the washing machine. The Laundry Personnel acknowledged that these containers were filled with chemicals and should have been stored above ground. The Administrator confirmed that nothing should be on the ground in the laundry room and that all items should be stored at least four inches off the ground. Despite requests, the facility's policy and procedure on chemical storage were not provided.
Failure to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to maintain a homelike environment for one of its residents, identified as Resident 87. During an observation and interview, it was noted that a breathing exercise device labeled with another resident's initials was hanging on the wall in Resident 87's room. Resident 87 expressed discomfort and confusion about the presence of items that did not belong to him. A Certified Nursing Assistant (CNA) confirmed that the belongings in Resident 87's room belonged to a different resident, Resident 77, who had already moved to another room. The facility's policy on maintaining a homelike environment emphasizes the importance of residents using their personal belongings and having personalized room arrangements, which was not adhered to in this instance.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to ensure timely notification to the Long Term Care Ombudsman regarding the transfer and discharge of two residents, Resident 89 and Resident 90. For Resident 89, the Transfer or Discharge Fax Cover Sheet Ombudsman Program (TDFCSO) dated 8/2/24 indicated a discharge, but there was no fax confirmation that the ombudsman received the notice. During an interview, the Social Services Supervisor (SSS) admitted uncertainty about whether the notification was received, as there was no fax confirmation. Similarly, for Resident 90, the TDFCSO dated 9/2/24 also lacked fax confirmation of receipt by the ombudsman. The SSS acknowledged that the discharge notification should have been completed within 30 days of discharge, but there was no evidence of the fax being sent. The facility's policy and procedure on transfer and discharge required maintaining evidence that the notice was sent to the Ombudsman, which was not adhered to in these cases.
Failure to Implement Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to implement interventions to prevent skin breakdown for a resident, identified as Resident 51, who was at high risk for developing pressure ulcers. During an observation and interview, it was noted that Resident 51's heels were not elevated and were touching the bed, despite having non-blanchable redness on the left heel, which can indicate a pressure ulcer. The Licensed Vocational Nurse (LVN) confirmed that the resident's heels were supposed to be elevated to prevent skin breakdown. The resident's Order Summary Report indicated the use of a 'heels up' device to monitor for proper placement every shift due to a history of blanchable redness. The resident's Braden Scale score was 12, indicating a high risk for skin breakdown, and the care plan specified the need for a 'heels up' device to protect the skin while in bed. Additionally, the Minimum Data Set (MDS) noted that the resident had limited range of motion in both lower extremities and required total assistance with bed mobility. The facility's policy on pressure ulcers required documentation and reporting of current treatments, including support surfaces, which was not adhered to in this case.
Failure to Reorder and Notify of Unavailable Medications
Penalty
Summary
The facility failed to adhere to its policy and procedures regarding medication reordering and handling unavailable medications, resulting in a deficiency. A licensed nurse did not reorder medications in a timely manner, failed to notify the physician of unavailable medications, and did not obtain alternative orders for a resident. This led to the resident not receiving physician-ordered diabetic medications, which are crucial for managing blood sugar levels. The resident missed doses of several medications, including Admelog, Jardiance, Lasix, and Tresiba, due to the medications not being available from the pharmacy. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that medications should have been reordered at least seven days before running out, and the physician should have been notified of missed doses. The facility's policy required immediate action when medications were unavailable, including notifying the physician and obtaining alternative treatment orders. However, there was no documentation of physician notification or pharmacy contact regarding the missed medications. The facility's policy also stated that medications should be reordered when six or fewer doses remain, which was not followed in this case.
Failure to Follow Physician's Order for Thickened Liquids
Penalty
Summary
The facility failed to adhere to the physician's order for a resident requiring nectar thick consistency beverages, which could potentially lead to a choking incident. During an observation, it was noted that the resident had unthickened juice on their bedside table, and a CNA confirmed that the resident consumed thin liquids, despite the order for nectar thick consistency. Additionally, the Certified Dietary Manager was unaware if the resident's soda was being thickened as required. The resident's Order Summary Report indicated a diet order of regular diet puree texture with nectar thick consistency, but the care plan did not address the resident's noncompliance with the diet order. Interviews with the DON and another CNA revealed that the thickener was available at the nurses' station, but the care plan for the resident's risk for dehydration did not specify the need for nectar thick liquids. The facility's policy stated that only commercially-prepared thickened liquids should be used, but this was not followed in the resident's case.
Failure to Honor Resident's Food Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, which had the potential to result in unmet nutritional needs. During an observation and interview, the resident expressed dissatisfaction with the meal provided, which included brussels sprouts, mashed potatoes and gravy, and pot roast. The resident, who was cognitively intact with a BIMS score of 13, stated a dislike for brussels sprouts and indicated that once they were on his plate, he would not eat the meal. The resident could not recall what he had ordered but was certain he did not request brussels sprouts. A review of the resident's meal ticket and nutrition evaluation revealed that the resident had specified dislikes for certain vegetables, preferring only corn, peas, and green beans. The facility's policy and procedure for food substitutions indicated that residents should be offered a suitable nourishing alternate meal if they refuse the planned meal. However, this policy was not followed, as the resident was not provided with an alternative meal after expressing his refusal to eat the brussels sprouts.
Improper Food Temperature for Residents
Penalty
Summary
The facility failed to ensure that food was served at the proper temperature for two residents, resulting in meals being served at unappetizing temperatures. During observations and interviews, it was noted that one resident received a breakfast tray with lukewarm waffle, toast, and sausage patty. Another resident reported that her breakfast, including French toast, oatmeal, and sausage, was cold, with a specific complaint about the oatmeal always being cold. A subsequent temperature check of the food items revealed that the sausage patty was at 108.6°F, French toast at 101.3°F, milk at 59.8°F, and cranberry juice at 61.6°F. According to the Dietary Supervisor, the milk should have been at least 45°F, and the waffle, French toast, and sausage should have been at least 120°F. The facility's policy indicated that hot entrees should be greater than 120°F and milk or cold beverages should be less than 45°F.
Failure to Ensure Staff Wear Name Tags
Penalty
Summary
The facility failed to ensure that four out of five sampled Certified Nursing Assistants (CNAs) were wearing name tags, which resulted in residents and visitors being unable to identify the staff providing care. This deficiency was identified through observations, interviews, and record reviews. Family Member 1 expressed difficulty in identifying staff due to the absence of name tags. Similarly, Resident 1 reported being unable to identify staff for the same reason. During an observation, CNA 1 was seen assisting residents without a name tag and admitted to misplacing it without requesting a replacement. The Director of Staff Development confirmed that all staff were expected to wear name tags. Further observations revealed that CNAs 3, 4, and 5 were also not wearing name tags. CNA 3 and CNA 4 both acknowledged forgetting their name tags, while CNA 5 admitted to losing his. The facility's policy and procedure on identification badges, dated 2023, mandates that all employees wear identification badges during work hours, which should be clearly visible and include the employee's first name, last name, and job title. The failure to adhere to this policy led to the deficiency noted in the report.
Failure to Report Abuse Allegations Promptly
Penalty
Summary
The facility failed to implement its abuse policy for two residents when an allegation of abuse was not reported to management by a staff member. A Licensed Vocational Nurse (LVN 1) was informed by another resident that two residents were afraid of a Certified Nursing Assistant (CNA 2) due to alleged physical and verbal abuse. Despite being informed of these allegations, LVN 1 did not report them to management, believing that the resident had already informed the Director of Nursing (DON). LVN 1 intended to discuss the allegations with the DON upon returning to work six days later, acknowledging that she should have reported the allegations immediately. Interviews with the Assistant Director of Nursing (ADON) and the Administrator confirmed that staff members are expected to report any allegations of abuse immediately to ensure resident safety. The facility's policy and procedure on abuse, neglect, and exploitation require reporting all alleged violations to the Administrator and relevant authorities within specified timeframes, particularly within two hours if the allegations involve abuse or result in serious bodily injury. The failure to report the allegations promptly had the potential to delay the investigation and place other residents at risk for abuse.
Failure to Notify Physician and Responsible Party of Resident Injury
Penalty
Summary
The facility failed to ensure the Physician and Responsible Party (RP) were notified of an injury for one of three sampled residents. This deficiency was identified during a review of the SBAR dated 4/20/24, which indicated a fall. Further review of the resident's Progress Notes dated 4/21/24 revealed that the resident returned from the emergency room with abrasions to bilateral shins. During an interview and record review with the Director of Nursing (DON), it was confirmed that there was no evidence of the Physician and RP being notified of the abrasions. The facility's policy and procedure titled Notification of Changes, dated 5/1/22, requires informing the resident, consulting with the resident's physician, and notifying the resident's family member or legal representative when there is a change requiring such notification, including accidents resulting in injury.
Call Light Malfunction
Penalty
Summary
The facility failed to ensure that a resident's call light was in working order, which had the potential for staff to be unaware of the resident needing assistance. During an observation in the resident's room, it was noted that pressing the call light button did not activate the call light outside the room or in the hallway. A Certified Nursing Assistant (CNA) confirmed the malfunction and stated that the resident used the call light to request assistance. The Maintenance Director inspected the call light and confirmed it was not working. The facility's policy and procedure indicated that the call light should be functional at all times, but this was not adhered to in this instance.
Failure to Complete Physician-Ordered Wound Care and Monitoring
Penalty
Summary
The facility failed to ensure that monitoring and wound care were completed as ordered by the physician for two residents. For Resident 1, the Order Summary Report (OSR) indicated that the resident's right heel should be monitored for signs and symptoms of worsening or infection every shift for 21 days. However, the Treatment Administration Record (TAR) showed that monitoring was not documented on three occasions. The Treatment Nurse confirmed that if the documentation was not on the TAR, the monitoring was not done. For Resident 2, the OSR included multiple orders for wound care and monitoring of various areas, including the sacral wound, left heel, right heel, left hand, facial flushing, right elbow, and other areas. The TAR indicated that treatment was not done on one occasion, and monitoring was not done on four occasions. The Treatment Nurse and the Director of Nursing both confirmed that treatments and monitoring should have been documented on the TAR, and the lack of documentation indicated that the care was not provided as ordered.
Failure to Notify Physician of Unadministered Medication
Penalty
Summary
The facility failed to notify the physician when a resident was not administered prescribed medications, specifically Bumetanide, which is used to remove excess fluid from the body and is vital for managing congestive heart failure. The Medication Administration Record (MAR) for December 2023 showed that Bumetanide was not given on three consecutive days, and there was no documentation indicating that the physician was informed of this lapse. The Progress Notes indicated that the medication was not administered due to awaiting pharmacy refill and pending delivery. During an interview and record review, the Director of Nursing (DON) confirmed the absence of evidence that the physician was notified about the unadministered medication. The facility's policy and procedure for Medication Administration, dated January 2021, requires that the physician be notified if two consecutive doses of a vital medication are withheld or refused. This oversight had the potential to lead to health complications for the resident.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to adhere to its medication administration policy and procedure, resulting in an inaccurate Medication Administration Record (MAR) for one of the sampled residents. The MAR for December 2023 showed that several medications, including Amiodarone, Aspirin, Bumetanide, Carvedilol, and Omeprazole, were not documented as administered on specific dates. The MAR was left blank for the administration times, indicating that these medications were not given to the resident. During an interview and record review, the Director of Nursing (DON) confirmed that the medications were administered on the specified dates but were not documented on the MAR. The facility's policy requires that the individual administering the medication record the administration immediately on the MAR, which was not followed in this instance. This oversight led to an inaccurate MAR for the resident, who was receiving treatment for conditions such as irregular heart rate, coronary artery disease, congestive heart failure, hypertension, and gastroesophageal reflux disease.
Failure to Develop Baseline Care Plan for Wound
Penalty
Summary
The facility failed to develop a baseline care plan for a resident who was admitted with a partial thickness wound to the coccyx area. This deficiency was identified during a review of the resident's progress notes, which indicated the presence of the wound upon admission. During an interview and record review with the Director of Nurses (DON), it was confirmed that there was no documented evidence of a baseline care plan for the wound. The facility's policy and procedure require a baseline care plan to be developed within 48 hours of admission to address the resident's immediate health and safety needs.
Failure to Provide Wound Care as Ordered
Penalty
Summary
The facility failed to ensure wound care was provided according to physician orders for one of three sampled residents. Resident 1 had an active order for wound care to be performed daily, which included cleansing with a wound cleanser, applying medi honey, and covering with a border gauze. However, a review of the Treatment Administration Record (TAR) revealed that the wound care was not documented as provided on three specific dates. The Director of Nurses confirmed that the wound care was not administered on those dates. The facility's policy and procedure for wound treatment management requires that wound treatments be provided in accordance with physician orders and documented accordingly, which was not followed in this case.
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Two residents with dementia, schizoaffective disorder, and major depressive disorder, both with moderately impaired cognition and needing moderate ADL assistance, were found unclothed together in one resident's bed. One resident later stated she did not want sexual activity and did not consent, while the other resident could not recall the encounter. An LVN reported that both residents verbally consented at the time but acknowledged no assessment had been done to determine their capacity to consent to sexual activity. The DON identified the incident as sexual abuse and confirmed that allowing sexual activity without prior capacity assessment was inconsistent with facility policy and that the resident was not protected from sexual abuse.
Two residents with dementia, schizoaffective disorder, major depressive disorder, and moderately impaired cognition, both needing moderate assistance with ADLs, were found unclothed together in one resident’s bed. The resident later stated she did not consent to sexual contact, while the other resident did not recall any sexual activity. An LVN documented the incident and acknowledged it constituted sexual abuse that should have been reported immediately to the abuse coordinator and appropriate agencies, but did not report it. The administrator, who serves as the abuse coordinator, stated she relies on staff to notify her immediately of such allegations so they can be reported to CDPH, law enforcement, and the Ombudsman, but this did not occur, resulting in the allegation not being reported as required.
A resident with Parkinson’s disease, osteoporosis, and osteoarthritis reported being punched in the face by another resident, resulting in facial bruising. The resident’s MDS showed intact cognition, and a change in condition evaluation documented the assault; however, the MD was not notified until more than a day later. The care plan directed licensed nurses to assess the resident’s body, and staff observed a purplish bruise on the right lower eyelid/orbital area, but this was not documented in the progress notes. Required every-shift monitoring for 72 hours after the change in condition was not documented on multiple day shifts. The DON confirmed lack of awareness of the bruise and acknowledged missing documentation and monitoring, despite facility policies requiring immediate provider notification and complete, accurate charting of changes in condition.
A nurse left a medication cart unlocked and unattended in the hallway while administering insulin to a resident with diabetes, cardiac, and post-surgical conditions. The cart was out of the nurse's direct line of sight, contrary to facility policy requiring medication carts to be locked when not in use. The DON confirmed that medications should be secured to prevent unauthorized access.
A resident’s legal representative requested copies of the resident’s medical records through a faxed request from a law office’s third-party service, but the records were not provided within the required timeframe. The MRD confirmed receiving the request and stated he had forwarded the documents to the DON for review over a month earlier and had not received them back to release. Upon review of federal requirements for record access, the ADON acknowledged that the facility did not comply with the regulation requiring provision of copies within two working days of request.
Two CNAs violated privacy and confidentiality requirements when one CNA used a personal cell phone to record and photograph two residents during a perceived altercation and then sent the video to another CNA. The residents, who had significant medical conditions including paraplegia, seizures, dysphagia, and severe cognitive impairment, were dependent on staff for ADLs. The second CNA reported that a family member later took her phone without permission, accessed the contents, and transmitted the videos and photos to facility leadership. Facility staff, including an LVN, the DSD, and the administrator, stated that HIPAA rules and facility policies prohibit staff from recording residents on personal devices and allow resident photographs only with consent and for medical purposes as part of the chart, and that the facility’s "Stop and Watch" process requires observation and reporting, not filming.
A resident with a stage 4 sacrococcygeal PI, Parkinson’s disease, hypertension, moderate cognitive impairment, and high assistance needs was not provided care consistent with the facility’s pressure injury prevention policy. Although the care plan included daily wound treatment and use of a LAL mattress, it lacked an individualized repositioning schedule and did not document education or reminders about repositioning. Facility documentation showed only that the resident was assisted to roll each shift, with no evidence of q2h turning in bed or of how often incontinence briefs were checked and changed. After the resident refused Foley catheter reinsertion, the IDT did not identify incontinence as a risk factor or add new wound-protective or moisture-preventive interventions, and the subsequent care plan for non-compliance omitted such measures. The TXN and DON confirmed that repositioning and protection of the wound from incontinence were not clearly implemented or reflected in the care plan, despite policy requirements.
A resident with Parkinson’s disease, cognitive impairment, and significant assistance needs for mobility and toileting experienced two early-morning falls resulting in head injuries. After the first fall, the IDT documented potential interventions such as a bed alarm and floor mat but did not identify the cause of the fall, did not obtain a physician order for the floor mat, and did not ensure the care plan addressed supervision or bed alarm function. Before and after the falls, the care plan lacked interventions for supervision despite poor safety awareness and failure to use the call light, and the second fall occurred when the resident slid from bed while reaching for a snack bag placed on the bedside table. IDT follow-up documentation for the second fall was incomplete, and staff acknowledged that fall causes were not identified and resident-centered interventions were not fully implemented.
A resident with severe cognitive impairment and multiple neurological diagnoses was dependent on staff for hygiene and mobility. During an IDT meeting, the resident’s family member communicated specific care preferences, but facility staff did not develop or update a comprehensive person-centered care plan to include these preferences. Review of care plans over several months showed no documentation of the communicated preferences, despite facility policy requiring the IDT to create a measurable, time-framed care plan based on assessed needs and expressed preferences.
A resident with COPD and severely impaired cognition, dependent on staff for all ADLs and mobility, had a physician order for continuous supplemental O2 at a fixed rate of 2 L/min. During observations, the resident was found receiving O2 at 3 L/min. An LVN recognized the discrepancy and reported it to an RN supervisor, but there was no documentation of any clinical rationale for the increased flow, no physician notification, and no order change. The care plan directed staff to administer O2 as ordered, and facility policy required verification of the order, documentation of flow rate and rationale, and appropriate reporting, which were not followed.
Failure to Protect Cognitively Impaired Resident From Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when two cognitively impaired residents were found unclothed together in one resident's bed without prior assessment of their capacity to consent to sexual activity. One resident had dementia, schizoaffective disorder, and major depressive disorder, with documentation of fluctuating capacity to understand and make decisions and a Minimum Data Set (MDS) indicating moderately impaired cognition and a need for moderate assistance with ADLs. During an interview at her bedside, this resident stated she did not want to engage in sexual activity and did not consent to sexual contact with the other resident. The second resident involved also had dementia, schizoaffective disorder, and major depressive disorder, with an MDS showing moderately impaired cognition and a need for moderate assistance with ADLs. In an interview, he stated he liked women and liked to socialize with women but could not recall whether he engaged in sexual activity with the first resident. An LVN reported observing both residents unclothed in the first resident's bed and stated that, at the time of the incident, both residents verbally consented to sexual activity, but she was not aware of any assessment having been performed to determine either resident's capacity to consent. The DON stated the incident was considered sexual abuse, that it was not the facility's practice to allow sexual activity without appropriate assessment, and that the facility failed to ensure the resident was protected from sexual abuse, contrary to the facility's abuse prevention policy.
Failure to Report Alleged Sexual Abuse Between Cognitively Impaired Residents
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of sexual abuse between two residents to the State Survey Agency, Ombudsman, and local law enforcement as required by federal regulations and the facility’s own abuse reporting policy. A nurse documented that one resident (Resident 2) and another resident (Resident 4) were found unclothed together in Resident 2’s bed, and the nurse acknowledged that this situation constituted sexual abuse and should have been reported immediately to the abuse coordinator and appropriate agencies, but she did not report the incident. The facility’s policy stated that all staff are mandated reporters and must notify appropriate authorities within two hours of becoming aware of abuse and immediately notify the Abuse Prevention Coordinator and their supervisor. Resident 2 had dementia, schizoaffective disorder, major depressive disorder, fluctuating capacity to understand and make decisions, and moderately impaired cognition, and required moderate assistance with ADLs. During an interview at her bedside, Resident 2 stated she did not consent to sexual contact with Resident 4. Resident 4 also had dementia, schizoaffective disorder, major depressive disorder, moderately impaired cognition, and required moderate assistance with ADLs, and stated he did not recall engaging in sexual activity with any residents. The Administrator, who served as the abuse coordinator, stated she was responsible for reporting all abuse allegations to CDPH, law enforcement, and the Ombudsman, and that staff were responsible for notifying her immediately of sexual abuse allegations so they could be reported and investigated. The failure of staff to notify the Administrator and report the incident resulted in the sexual abuse allegation not being reported as required, causing a delay in an onsite investigation by CDPH.
Failure to Assess, Notify, and Monitor Resident After Facial Trauma
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of nursing practice in assessing and monitoring a resident after a reported change of condition related to facial trauma. The resident was admitted with Parkinson’s disease, age-related osteoporosis, and osteoarthritis, and had intact cognitive skills for daily decision-making per a recent MDS. On the evening of 3/26/2026, a Change in Condition Evaluation documented that another resident hit this resident on the nose and both cheeks. The evaluation showed that the attending physician was not notified until 10 p.m. on 3/27/2026, approximately 26.5 hours after the reported incident, and the physician’s recommendation was to monitor the resident’s nose and cheeks for any changes and pain. The resident’s care plan, initiated on 3/26/2026, documented the report that another resident hit him on the nose and both cheeks and included an intervention for licensed nurses to check and assess the resident’s body. In an interview, the resident described that the other resident came into the room, stood on the left side of the bed, and punched him in the face. A photograph taken two days after the alleged incident showed a purplish-blue bruise on the right lower orbital area, although the resident declined to provide a copy of the picture. A CNA later reported observing a purple bruise on the resident’s right lower eyelid on 3/27/2026, described as extending from the inner to the middle lower eyelid and about the size of the tip of her fifth digit. During record review and interviews, an LVN stated that on 3/27/2026 the resident’s right lower eyelid had a dime-sized purplish bruise, but there was no documentation of this bruise in the progress notes. The LVN also stated that the resident should have been monitored every shift for 72 hours after the change of condition, yet there was no documented evidence of monitoring on the 7 a.m. to 3 p.m. shifts on 3/27/2026, 3/28/2026, and 3/29/2026. The DON reported not being made aware of the right eyelid bruise, confirmed that the resident should have been monitored every shift for at least 72 hours following the change of condition, and acknowledged there was no confirmed documentation of monitoring on the identified shifts. Facility policies required immediate physician consultation for significant changes in condition and complete, accurate documentation of changes and services provided, but the facility failed to identify, document, and monitor the resident’s change of condition in accordance with these policies.
Plan Of Correction
Facility Response Submission of the Plan of Correction does not constitute admission or agreement by the Provider of the truth of the facts alleged or conclusion set forth in this statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provision of Federal and State laws. This Plan of Correction constitutes the facility's credible allegation of compliance Corrective Action On 4/7/2026 Resident 1 was reassessed by LVN 3 and no skin issue was identified. On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Identification of other residents and corrective action On 4/8/2026 DON and/or designee reviewed audits provided by medical records for all change of condition in month of April to ensure proper documentation and monitoring are in place. No other deficient practice noted. Measures to prevent recurrence On 4/7/2026 LVN 3 received one-on-one in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. On 4/8/2026 Licensed nurses received in-service by DON regarding importance of documenting details about resident's change of condition and monitoring every shift for 72 hours. Monitoring and incorporation into the QA system HID will audit change of conditions using Change of Condition Audit form daily Monday-Friday and will report any finding during daily stand-up meeting Monday-Friday on-going. DON or designee will review change of conditions from prior day during daily clinical meetings (Monday -Friday) on going to ensure the nurse notified the attending physician regarding resident's significant change of condition and documented. Any deficient finding will be reported to DON and/or administrator for further corrective action/recommendation. Any trend of deficient finding(s) will be documented on Change of Condition Audit Form and will be reviewed during the monthly QA meeting for further review and/or recommendation(s). Administrator who will then report to the Quality Assurance (QA) team during monthly Quality Assurance (QA)/Quality Assurance and Performance Improvement (QAPI) for further evaluation/recommendation and to provide feedback and program modification if needed x3 months or until compliant. Date Corrective action to be completed: 4/8/2026
Medication Cart Left Unlocked During Medication Pass
Penalty
Summary
During a medication pass for a resident with a history of surgical aftercare, cardiac arrest, heart failure, and type 2 diabetes mellitus, a licensed nurse prepared and administered Novolog insulin using a pen-injector. The nurse left the medication cart unlocked and unattended in the hallway, approximately two feet outside the resident's bedroom doorway, while administering the injection inside the room. The cart was out of the nurse's direct line of sight during this time. The nurse acknowledged that the cart was left unlocked and should have been secured when not in direct view. Facility policy and procedure documents reviewed indicated that medication carts must be kept closed and locked when out of sight of the medication nurse or aide, and that compartments containing drugs and biologicals are to be locked when not in use. The Director of Nursing confirmed that medications should be locked and secured to prevent unauthorized access by unlicensed staff and residents. The failure to lock the medication cart during the medication pass was observed and confirmed through interviews and record review.
Plan Of Correction
From 4/4/2025 through 4/7/2025, the DON, DSD, and ADSD completed 1:1 inservices with licensed staff regarding the facility policy and procedure titled Storage of Medications. Medication carts must be kept locked when unattended. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 3 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 2 times a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will monitor medication carts being locked when unattended 1 time a week for 2 weeks. DON, IP, MDS, ADSD, or DSD will random monitor medication carts being locked when unattended for 1 month. System effectiveness will be evaluated during the facility's monthly Quality Assurance Performance Improvement Committee meetings for three (3) months.
Failure to Timely Provide Resident Medical Records Upon Request
Penalty
Summary
The facility failed to provide timely access to medical records as required under 42 CFR 483.10(g)(2) for one resident. The resident’s face sheet showed an admission date of November 18, 2025, with multiple diagnoses, but no additional clinical details were provided. A legal representative’s office faxed an initial request for the resident’s medical records on February 26, 2026. As of March 26, 2026, the legal representative’s staff reported that the office had not yet received the requested records from the facility. On April 2, 2026, the Medical Record Director (MRD) confirmed documentation that a third-party service for the law office had requested the resident’s medical records on February 26, 2026. The MRD stated he had submitted the requested documents to the Director of Nursing (DON) for review over a month prior but had not received them back to proceed with releasing the records. During a concurrent interview and record review, the Assistant Director of Nursing (ADON) reviewed the State Operations Manual Appendix PP guidance on residents’ rights to access personal and medical records, which requires that copies be provided within two working days of request. The ADON acknowledged that this regulatory requirement was not followed by the facility.
Plan Of Correction
F0573 Right to Access/Purchase Copies of Records What corrective action(s) will be accomplished for those Residents found to have been affected by the deficient practice? Medical Records Director (MRD) released medical records for Resident 1 as requested by the legal representative (Legal Staff) on April 21, 2026. How will other individuals with the potential to be affected by this deficient practice be identified and protected? No other Resident was identified to have been effected by the deficient practice. What systemic changes will be implemented to ensure that the deficient practice does not recur? The Quality Assurance Committee met on April 14, 2026 to review the Policy and Procedure which was then forwarded to the Knolls West Post Acute legal team for further evaluation. Revision of the policy will be discussed and approved by the Quality Assurance Committee to ensure the facility meets all Federal and State Regulations. F0573 Right to Access/Purchase Copies of Records (CONT.)The Administrator and the Medical Records Director (MRD) are responsible for informing the requesting party for the demand for payment for the requested medical documentation being provided and until payment is received the facility will hold the chart copies.How corrective action(s) will be monitored to ensure solutions are being achieved and sustainedThe Resident's Responsible Party will be notified upon receipt of the Medical Records Request and review in the presence of the facility representative. Records will be provided if it does not pertain to any legal matters after payment is received. The Administrator and/or Designee is responsible for reporting to the Quality Assurance Committee on a monthly basis and monitoring to ensure that corrective action is implemented and evaluated for its effectiveness. The same will be reviewed on a quarterly basis to the Quality Assurance Committee meeting x 3 quarters or until 100% compliance is achieved and sustained.Date of CompletionApril 23, 2026
Unauthorized Resident Recording and Disclosure Violating Privacy and Confidentiality
Penalty
Summary
The deficiency involves a failure to protect residents’ privacy and confidentiality when a CNA used a personal cell phone to record and photograph two residents without their knowledge or consent, and then shared that content with another CNA. One resident had paraplegia, depression, muscle weakness, dorsalgia, and polyneuropathy, was cognitively intact, and dependent on staff for ADLs. The other resident had diagnoses including seizures, dysphagia, acute kidney dysfunction, and muscle weakness, was able to make needs known but could not make medical decisions, had severely impaired decision-making, and was also dependent on staff for ADLs. Both residents were therefore in a position of dependence on staff for care at the time of the incident. According to CNA 2, on a specific date she recorded a video of the two residents because one resident started an altercation with the other. She stated she recorded the incident for “evidence” and to show CNA 1, acknowledging that recording residents was not part of facility policy and that she should not have recorded or taken photographs of them. CNA 1 confirmed that she received the video on her personal cell phone from CNA 2 and stated that the recording was made for “safety purposes” due to a situation that was perceived as potentially escalating to physical aggression. CNA 1 reported that she did not share or post the video on social media or distribute it to others, but that a family member took her phone without permission and accessed its contents. CNA 1 further stated that this family member sent the video and pictures of the two residents to the facility, and that she notified the facility that her phone had been taken but did not disclose that it contained videos or photographs of the residents because she was unaware that the family member had accessed or distributed them. The DSD reported receiving a text message from an unknown number containing approximately two videos and an undetermined number of photographs of the two residents, along with the names of CNA 1 and CNA 2. The DSD, LVN 2, and the Administrator each stated that staff were required to follow HIPAA regulations, that staff were not permitted to record or possess videos or photographs of residents on personal devices, and that any photographs of residents required consent and had to be for medical purposes as part of the medical record. Facility policies on confidentiality, residents’ rights, and dignity stated that unauthorized release, access, or disclosure of resident information, including video or audio, was prohibited and that staff must protect resident privacy and treat residents with dignity and respect. The videos received by the DSD did not show an altercation between the residents, and staff interviews confirmed that filming residents was not part of the facility’s “Stop and Watch” process, which instead required observation, intervention, and reporting of changes in condition or behaviors to nursing staff.
Plan Of Correction
This Plan of Correction is the facility's credible allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth or facts alleged, or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. F0583 Personal Privacy/Confidentiality of Records How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Corrective actions were immediately implemented for Resident 1 and Resident 2 upon identification of the deficient practice. The facility initiated an investigation on 03/23/2026 and conducted immediate interviews with staff and residents utilizing structured interview tools to assess scope, impact, and additional potential concerns. Interviews confirmed the incident was isolated and no additional residents reported privacy violations or concerns. The staff members involved were removed from duty immediately. Following completion of the investigation, both employees were terminated in accordance with facility policy due to violation of resident rights, HIPAA, and facility confidentiality policies. Both employees completed formal Declarations and Attestations of Deletion of Unauthorized Recordings, confirming removal of all recordings and non-distribution of content. Documentation includes: Ashley Zelaya, CNA – Declaration executed 03/30/2026 at 9:21 AM, attesting deletion of all recordings and acknowledgment of policy violation Leslie Bram Reyes, CNA – Declaration executed 03/26/2026 at 10:42 AM, attesting deletion of all recordings and acknowledgment of policy violation Residents and/or responsible parties were notified. Social Services completed assessments with no identified psychosocial harm. All corrective actions were completed by 03/26/2026. How the facility identifies other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A facility-wide audit was initiated on 03/25/2026 using the Briarcrest Comprehensive Privacy, Recording, and Resident Rights Audit Tool. The audit included direct observation, staff interviews, and resident interviews to evaluate compliance with privacy practices, personal device use, and HIPAA requirements. Interviews were conducted using standardized staff and resident interview tools to ensure consistency and thoroughness in data collection. Findings from the audit confirmed that no additional residents were affected by the deficient practice and no additional incidents of unauthorized recording or disclosure were identified. Staff were immediately re-educated by Director and staff development on HIPAA Privacy Rule requirements, the facility's prohibition on personal device recordings, and the appropriate use of the Stop and Watch process for reporting changes in resident conditions. This corrective action was completed by 03/27/2026. What measures will be put into place or what systemic changes will the facility make to ensure that the deficient practice does not recur. The facility implemented systemic changes to prevent recurrence of the deficient practice by reinforcing a zero-tolerance policy for unauthorized recordings and strengthening staff accountability related to resident privacy and confidentiality. Staff completed mandatory re-training by the Director of Staff Development on Resident Rights, HIPAA, and Privacy/Confidentiality requirements. Staff were required to re-acknowledge facility policies related to confidentiality and personal device use. The facility implemented routine supervisory rounding to monitor compliance with personal device restrictions. In addition, the facility installed visible signage at the receptionist area clearly articulates that video recording is strictly prohibited inside resident rooms and in any facility areas where residents are present. The facility also posted signage throughout the entire facility, in both English and Spanish, indicating that video recording is not allowed to ensure clear communication to staff, visitors, and all individuals entering the facility. Privacy and HIPAA compliance were further integrated into new employee orientation, annual competencies, and ongoing in-service education. The Director of Staff Development completed initial re-education by 03/27/2026, and staff completed required training by 04/05/2026. How the facility plans to monitor its performance to make sure that solutions are sustained. To ensure sustained compliance, the facility incorporated privacy and confidentiality monitoring into its Quality Assurance and Performance Improvement (QAPI) program. The facility implemented an ongoing monitoring system beginning on 03/25/2026 utilizing the established audit tool, which confirmed that no additional residents were affected, and no further incidents occurred during the initial audit period. The facility will continue monitoring through weekly audits for four consecutive weeks, followed by monthly audits for three months. These audits will include direct observation of staff practices, verification of compliance with personal device policies, and evaluation of adherence to HIPAA and privacy requirements. Audit findings will be documented using standardized tools and reviewed by the Director of Nursing, with results reported to the Quality Assurance and Performance Improvement (QAPI) Committee for analysis and trending. If any issues are identified, immediate corrective action will be implemented, including re-education and progressive discipline as appropriate. If no trends or repeat deficiencies are identified after the monitoring period, the facility will discontinue routine auditing and remove the issue from active QAPI monitoring. Dates when corrective action will be completed. 4/17/2026
Failure to Implement Repositioning and Moisture Management for Stage 4 Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to prevent deterioration of a stage 4 sacrococcygeal pressure injury in accordance with its own pressure injury prevention policy. The resident had a documented stage 4 PI of the sacral region, Parkinson’s disease, hypertension, moderate cognitive impairment, and required substantial/maximal assistance with toileting hygiene, rolling, and transfers. A Braden Scale score of 16 identified the resident as at risk for pressure injury. The Skilled Evaluation Nurse note indicated a pressure-reducing device for the bed but did not indicate that the resident was to be turned and repositioned every two hours. The resident’s care plan for the stage 4 sacrococcyx PI included cleansing with normal saline, applying Santyl ointment, and covering with dry and foam dressings daily, as well as providing pressure relief and a low air loss mattress to support body alignment and position. However, the care plan did not include an individualized repositioning schedule or education and reminders about the importance of repositioning. Documentation from the facility’s records showed that the resident was assisted to roll left and right every shift, but there was no documentation that the resident was turned and repositioned every two hours while in bed, nor was there documentation of the frequency of incontinence brief checks and changes after each episode. After the resident refused reinsertion of a Foley catheter, nursing progress notes documented the refusal but the IDT wound management conference record did not identify incontinence as a risk factor affecting healing of the stage 4 PI and did not document any new recommendations following the catheter refusal. A subsequent care plan addressing the resident’s potential for worsening condition related to non-compliance with Foley catheter reinsertion did not include wound protective measures or moisture-preventive interventions. During interviews, the treatment nurse acknowledged uncertainty about how often the resident was turned/repositioned or how frequently incontinence briefs were checked and changed, and confirmed that the care plan did not include measures to ensure turning at least every two hours or effective measures to protect the sacrococcyx PI. The DON stated that staff were supposed to ensure turning at least every two hours and protection of the wound dressing from incontinence, and that the IDT did not address this risk, so the care plan was not revised, despite facility policy requiring prompt cleaning after incontinence, use of barrier products, individualized repositioning schedules, and ongoing review of interventions for effectiveness.
Failure to Identify Fall Causes and Implement Supervision and Safety Interventions
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for a resident with significant fall risk. The resident had diagnoses including stage 4 sacral pressure ulcer, Parkinson’s disease, and hypertension, and was assessed as moderately cognitively impaired, with poor decision-making and a need for assistance with toileting, transfers, and ambulation. On one occasion, the resident was found on the floor at approximately 4:05 AM with a right forehead laceration requiring transfer to an acute care hospital for suturing. Following this first fall, the IDT Fall Management Follow-Up record listed interventions such as a medication regimen review, bed in lowest position, landing floor mat, and bed alarm, but there was no documented evidence identifying the cause of the fall. The resident’s care plan addressing strength and safety awareness deficits did not include supervision for safety despite poor safety awareness and not remembering to use the call light. The care plan for the actual fall with minor injury did not include ensuring that the bed alarm was functioning. Additionally, physician orders from 9/10/2025 to 1/29/2026 did not contain an order for a floor mat, despite this intervention being recommended in the IDT record. A second fall occurred at around 4:10 AM when the resident was again found on the floor next to the bed, holding a snack bag. The resident, described as alert but forgetful, stated that she had been trying to reach a snack bag on the bedside table and slid down from the bed, and redness was observed on the left side of the forehead after reportedly hitting the bedside table. The IDT Fall Management Follow-Up record for this second fall was incomplete, with no checked interventions. Interviews with the MDS nurse and DON confirmed that the IDT records should have identified the causes of the falls, that frequent monitoring and supervision were not care planned despite the resident’s cognitive impairment and poor safety awareness, and that the recommended floor mat was never ordered or applied, contrary to the facility’s own policies on assessing falls and developing comprehensive person-centered care plans.
Failure to Incorporate Resident Care Preferences Into Person-Centered Care Plan
Penalty
Summary
Surveyors identified a failure to develop a comprehensive person-centered care plan that incorporated a resident’s specific care preferences. The resident was readmitted on 8/31/2025 with multiple diagnoses, including metabolic encephalopathy, Alzheimer’s disease, blindness in the right eye, a history of TIA, and cerebral infarction without residual deficits. An MDS dated 10/30/2025 documented that the resident’s cognition was severely impaired and that the resident was dependent on staff for oral hygiene, toileting hygiene, personal hygiene, and movement. On 3/17/2026, the IDT met with a family member, who communicated specific care preferences for the resident. During interviews, the SSD and DSD confirmed that the family member had provided detailed care preferences at the 3/17/2026 IDT meeting, but a review of the resident’s care plans from 8/31/2025 to 3/31/2026 showed no documented care plan addressing those preferences. The DSD stated that a care plan should have been developed to reflect the resident’s care preferences, that it is the MDS nurse’s responsibility to develop the care plan, and that the absence of such a care plan could result in the preferences not being honored. The Administrator stated that the care plan is essential as it is used by staff as a guide to understand and implement the resident’s plan of care. The facility’s policy on Comprehensive Person-Centered Care Plans required the IDT to develop a comprehensive person-centered care plan with measurable objectives and time frames to meet identified needs, which was not done in this case.
Failure to Administer Oxygen Therapy as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to administer oxygen therapy as ordered by the physician for a resident with COPD. The resident was admitted with chronic obstructive pulmonary disease and had severely impaired cognition, requiring total staff assistance for all ADLs and mobility. A physician’s order dated 3/27/2026 directed that the resident receive continuous supplemental oxygen at a fixed rate of 2 L/min, with no indication that staff could adjust the flow rate. The resident’s care plan for altered respiratory status related to COPD instructed staff to administer oxygen as ordered. On 3/31/2026, during observations at the bedside at 8:45 a.m. and 9:40 a.m., the resident was noted to be receiving oxygen at 3 L/min, which did not match the physician’s order. An LVN reported that the resident was on 3 L/min when he checked vital signs that morning and stated this was not the ordered rate; he said he reported this to the previous shift’s RN supervisor but was unsure what action was taken. Another RN supervisor confirmed there was no documentation in the record to support an increased flow rate or any notification to the physician about the change from 2 L/min to 3 L/min, and reiterated that the order was for a fixed rate of 2 L/min. During a concurrent observation and interview, the prior RN supervisor acknowledged the resident was on 3 L/min and that the flow rate needed to be corrected to match the order. The facility’s oxygen administration policy required staff to verify a physician order, document the flow rate and rationale, and report information per professional standards, which was not followed in this instance.
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